MedStar Health DocTalk
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MedStar Health DocTalk
Stomach Cancer: Symptoms, Diagnosis, and Treatment Pathways
Stomach cancer, often referred to as gastric cancer, is a sneaky cancer. Its symptoms can be easily mistaken for more benign conditions like indigestion or acid reflux, making early detection a challenge. In our latest podcast episode, we delve into this complex disease with the help of two esteemed experts: gastroenterologist Dr. Walid Chaloub, and Dr. Reetu Mukherji, a medical oncologist from MedStar Georgetown Cancer Institute in D.C.
Host Debra Schindler explores the biology of stomach cancer with her physician guests to understand how mutations in the DNA of stomach cells can lead to uncontrolled growth and tumor formation. This formidable disease often goes unnoticed until it has advanced significantly, highlighting the critical need for awareness and early detection.
Dr. Mukherji shares the various risk factors associated with stomach cancer, including smoking, diet, and certain bacterial infections like H. Pylori. She emphasizes the importance of molecular testing in diagnosing and treating this disease, as it can reveal specific mutations that may be targeted with personalized therapies. The episode also explores the different diagnostic tools available, such as endoscopy and CT scans, and the role of tumor markers in assessing the presence of cancer. While these tools are invaluable, Dr. Mukherji stresses that they are not foolproof, underscoring the importance of comprehensive testing and expert analysis.
One of the most enlightening parts of the discussion is the potential for treatment and even cure. While surgery is a common approach, not all patients are candidates. The podcast highlights the evolving role of chemotherapy, immunotherapy, and targeted therapies, offering hope to those battling this disease. Listeners will gain a deeper understanding of the symptoms to watch for, the importance of genetic predispositions, and the latest advancements in treatment. This episode is a must-listen for anyone interested in learning more about stomach cancer, whether for personal knowledge or to support a loved one. Tune in to this informative episode to arm yourself with the knowledge needed to recognize the signs of stomach cancer early and explore the treatment options available. Your Health, or that of someone you care about, could depend on it.
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Comprehensive, relevant and insightful conversations about Health and medicine happen here when MedStar Health doct talk. These are real conversations with physician experts from around the largest healthcare system in the Maryland D.C. region. Abdominal pain, heartburn and fatigue might be the symptoms of overeating, indigestion or acid reflux, but they can also be the result of stomach cancer. It's a sneaky cancer with symptoms that could be insignificant and easily dismissed. That's a common theme among survivors of stomach cancer who often say they ignored the early signs of the disease. When it's most treatable and it is treatable, is it curable? We're going to get answers to that question and more during this week's episode of MedStar Health doct talk. Let's meet our guest physicians. Welcome MedStar Health gastroenterologist Dr. Walid Shalub and medical oncologist Dr. Ritu Mukherji at MedStar Georgetown Cancer Institute. I'm your host, Debra Schindler. Doctors, thank you for sharing your expertise with us today on doctalk.
>> Dr. Walid Shalub:Hi Deb, thank you for having us.
>> Dr. Ritu Mukherji:Happy to be here.
>> Debra Schindler:Debah Stomach cancer, also known as gastric cancer, occurs when the DNA in stomach cells mutate, causing the cells to grow out of control and form a tumor in the lining of the stomach. Is that a fair description?
>> Dr. Walid Shalub:Pretty much, to a certain extent. It is pretty accurate. Just like any cancers, the DNA does mutate, and those cells start grow out of control and they do form tumors or cancers. But specifically with gastric cancer, its a very difficult cancer to screen for, you know, with, for example colonoscopies. You know, theres science behind hundreds, not millions of patients have been studied over multiple decades on how you screen for colon cancer. there's newer guidelines know on how to screen for pancreatic cancer as well just because a lot of data has been coming in for it. For gastric cancer, the screening remains very, tight because the patients that we do screen usually have, hair ter disorders with hair ter diffus gastric cancer or patients with prior histories of gastric cancers or larger polyps within the stomach that were found incidentally when you were doing upper endoscopy. So that's why the screening guidelines aren't very, very clear still. And they're not very, ab broadad amongst the population. So there's no specific age where you start screening for them, at least in America. And different populations have different risks to develop them. And that's why there's not one screening mechanism to screen them all at the same time?
>> Dr. Ritu Mukherji:Absolutely. I think, you know, many patients wonder, what is a cancer? How does it start? And kind of what you alluded to earlier, you know, it is when really one cell, something goes wrong, the DNA becomes mut or altered, and essentially at the level of the gastric epithelium, there's just growth, abnormal growth of these cells until comes less and less like normal gastric tissue until it's something abnormal. And cancers, can grow into be, you know, diffusede things that spread throughout the stomach wall. They can grow to be masses and then, you know, g. Given enough time, they can also, start to spread locally and flick off little cancer cells in the bloodstream that can go to lymph nodes and potentially other organs farther away.
>> Debra Schindler:Why does this happen with, the mutation of these cells in the stomach? But is it genetics? Is it environment? I was surprised to read that cigarettes play a role sometimes in stomach cancer. I mean, we expected it with lung cancer and maybe esophageal cancer, but stomach cancer was a surprise to me.
>> Dr. Ritu Mukherji:I think there's a couple different, different, you know, reasons for why someone may develop a stomach cancer. And it's probably, you know, a combination of the things that you've mentioned. So some of the known risk factors or things like smoking and alcohol, these are things that essentially cause stress and inflammation at the level of the cells in the stomach. And these can lead to mutations and alterations. We also know that there are certain bacterial infections that can increase the risk of stomach cancer. For instance, H. Pylori, which is a bacteria that can grow in the stomach. Absolutely. There are hereditary conditions that can predispose people to developing these stomach cancers, not just stomach cancer, but maybe even other cancers in other parts of their body. You know, we even know things like diet can contribute to the risk of stomach cancer. So high salted foods, foods high in salt, even foods high in nitrates and processed red meats have been linked to the development of stomach cancers as well. And really probably causing some form of inflammation and irritation and DNA damage through different mechanisms that lead to the development of cancer.
>> Dr. Walid Shalub:Just to piggyback on what Dr. Mukachji was saying, they don't go from zero to cancer right away. Right. So there's multiple stages of how the cells change in the lining of the stomach. Start with, something called intestinal metaplasia, which increases the risk of them becoming cancerous. And then that metaplasia can change into dysplasia, and then that dysplasia changes into high grade dysplasia. That eventually changes into cancer. All those levels of how people start getting this metaplasia are affected, Just like Ron was saying. In terms of an environment, if you're talking, for example, in Japan, they have such a higher risk of, gastric cancer because of the salted foods in nitrous. They e with the sushi. They do have a higher rate than anybody else in the world you were talking about. There is a community in China that Dr. Fleischer was studying specifically for esophageal, because esophageal and gastroric canc are very similar. And that community used to cook with coal and be around coal a lot and be around fume. So those were also seen, I think up 70 times higher than the regular population in developing gastric cancer. So the environment really, truly does affect your propensity and you being prone to getting it. So, so genetics for sure, and then the environment for sure, and then how you, treat your body also, you know, that is very important to keep in mind. One thing I just want to say, just because gastric cancer is one of those cancers that can slowly progress without you feeling it know, and just like you when you first started debah talking, you say a lot of people just let those symptoms go unn noice a little epigastric pain, refluxory orlic satiety there. And the cancer itself has a lot of space to grow as well, because the stomach is an open pouch, right? So a lot of the times they grow and grow and grow and grow and grow. And then by the time you diagnose them, they're already big enough that they'already test theize and it's too late. So, it is very important to always take your symptoms very seriously if you are feeling them, you know, because if people start losing weight or abdominal pain or suffering nauseous, have trouble swallowing, if it's for example, more of a proximal cancer in the stomach, more towards the end of the esophagus. People for exampancele start see blood in their stool or people who start to get anemic. You know, those are all patients. we have to look out for patients with ulcer type pain, they stabbing pain in the stomach, that, you know, those are patients that we need to be very aware of in general, as also also patients who might have a, higher risk or need to be screened earlier, need to be looked at earlier.
>> Debra Schindler:At what point do you suspect cancer that you want to further and maybe do an endoscopy?
>> Dr. Walid Shalub:Some of them are Asymptomatic because there's no mass yet. This is just the cellular level just changing. So these are the patients specifically with the intestinal metoplasia. Those are the patients you want to jump on first, and foremost, make sure that you get a very, very adequate upper endoscopy. Get something called mapping of the stomach. So, you take biopsies from all around the stomach, and the stomach is divided anatomically into different places. And you make sure that you biopsy all those places and you figure out where exactly those cells came from. Because cancer obviously doesn't just grow in the whole stomach. Right. It grows in a part of the stomach. Most of.
>> Dr. Ritu Mukherji:Most of them.
>> Dr. Walid Shalub:Most of them, or in a part of the stomach. So we need to figure out where those cells are metaplastic or where those cells are transforming. Is it on the greater curvature of the stomach, the lesser curvature of the stomach towards the distal stomach? So that's what. If you can identify where these cells are changing earlier, that's how it's much easier for you to go back every year or two or three to make sure that that specific area didn't change and that specific area didn't develop a growth or those cells didn't change more because those are the cancers that you can catch earlier and have them treated, resected. and then you. And then obviously you cure a patient like that.
>> Debra Schindler:I mean, how would a patient know to ask for mapping? Under what circumstance would they be coming in in to see you?
>> Dr. Walid Shalub:And then that is very important. So they do come in with the symptoms that just. I was saying epigastric pain is a big part of it. Okay. a nausea is a big part of it. They come in, you take a look at the stomach. Usually metaplastic areass in stomach are redder. They have some erosions to them. So they present with these symptoms. M. But again, most of them don't present with any symptoms. And they'getting EGTs for reflux. And you go in and you find this red area or this nodular area in the stomach. So a lot of them are incidental as well.
>> Debra Schindler:Okay. Another thing that you said I want to ask about was that use. You use the term polyps, is that interchangeable with tumors or is that also like as. As with colon cancer? Is that a pre cancr in the stomach?
>> Dr. Walid Shalub:So different types of polyps in the stomach are a little different than polyps in the colon. Most polyps in the colon are something called a tubular adenoma. And these are precancerous lesions, that if left in place long enough, will develop into ganser gastric polyps. There's different types of gastric polyps. There's something called a fundic gland polyp, which is totally benign. So those are polyps there. But you don't have to say most people have innumerable ones. And then you don't take them all out. You just sample some of them. And if you do prove that they are funic and polyps and most of them are less than 1cm in size, if you do sample some of them and they do come out to be funded gland poppsy, just let that patient be. You don't have to send them for genetic testing or to oncologists or for gastrectomies or what have you. But there's other types of bos, like hyperlastic polyps as well. They're not tumors either. They're not cancers. But if they do grow again more than 1cm in size, recent data has shown that these polyps, if they do grow, tend to, have some potential for malignant transformation. So those pulyps that are bigger than 1cm in size, that a hypoplastic need to be resected completely because they can put you at a risk of developing stomach cancer. So, in short, gastric polyps are very different than stomach polyps because their pathology is different. But you can also have adenomas in the stomach as well. Those act very similar to colon polyps, and those are the ones that mostly, turn into cancer if not resected.
>> Dr. Ritu Mukherji:When we talk about polyps, correct me if I'm wrong. These are kind of findings during endoscopic procedures, but really biopsying them and taking a look, microscopically with what's going on in the polyp gives us an answer as to whether it's benign or if there's something more aggressive going on, like an invasive malignancy. So, you know, a polyp can be something completely benign, but it can also, you know, sometimes when it looks abnormal, bigger or more aggressive, endoscopically, taking a biopsy and making sure it's nothing more than benign. Leion is important.
>> Debra Schindler:Are you the physician who would take that biopsy, Dr. Shub, or is, that. Refer that to a surgeon. Okay.
>> Dr. Walid Shalub:No, no, no. We take the biopsies. We. We do most of the resections if they're benign polyps. There are some different types of treatment for gastric cancer, specifically early gastric cancers, and these are neurotypes of treatments called esd, endoscopic subicosal dissection. Because again, with cancer, just like I was, like Both me and Dr. Muer were describing, these cells, go in stages and phases before they become cancerous. So if, let's say portion of the stomach was metaplastic and went into dysplasia.
>> Debra Schindler:Let me pause you a minute. Metaplastic. Can you define.
>> Dr. Walid Shalub:Metlastic is the early transformation of a cell from normal. So let's say normal is zero and cancer is five. Metaplastic is the first transformation at level one. Level two would be dysplastic, Level three would be high grade dysplastic. And then level four would be early cancer. Level five would be cancer.
>> Debra Schindler:Got it. And then there's different types of cancers.
>> Dr. Walid Shalub:Many, many, many different types.
>> Debra Schindler:Oh, we don't need to name them all here. But what are the most common types of cancers?
>> Dr. Ritu Mukherji:So when we say stomach cancer, There are many different types of cancers that we could be alluding to. And it is so important to understand what specific type of cancer it is that we're talking about because are treatments and the prognosis vary so much based on the subtype. So really the most common cancer when we're talking about stomach cancer is adenocarcinoma. this is cancer that starts in the glandular cells, the glandular tissue of the stomach. This is some, someone in the same family of the common colon cancer, breast cancers that you hear out there. These are cancers that start in glands in those organs. So stomachoc carcinome really is the most common one. But certainly there are other types of cancers that can arise. There are things like neuroendocrine tumors that are very different from adenocarcinoma. They arise from different cells, they behave differently, Treatment is different. We can even see things like lymphomas, which are cancers that arise in the cells that form our immune system, our lymphatic channels. So it's very important to get a biopsy when we're trying to identify what it is that we're dealing with. I think a lot of our discussion today will be tailored towards, stomach adenocarcinoma, really the common one that we see for stomach cancer awareness month. And to really confirm that's what we're dealing with, we need a biopsy and tissue confirmation.
>> Debra Schindler:I have a list here of symptoms that, most of the materials that I read in my research came up with, a feeling bloated after eating, feeling full after eating, nausea, heartburn, indigestion, blood in the Stool, vomiting, weight loss for no reason, stomach pain. Now, if a patient comes in, we've already established that this could mean a lot of different things. When do you start to suspect stomach cancer? And what's the first step in diagnosing a patient?
>> Dr. Walid Shalub:There's all these symptoms that you are describing. Some of them are called alarming symptoms. And alarming symptoms are things like unintentional weight loss, things like blood in the stool, things like early satiety. Those are very alarming symptoms. So those you actually jump on it right away. And the first thing you want to do is an upper endoscopy. All right? There's other things, just like some epigastric pain, some discomfort, some dyspepsia and nausea. Ah, you don't have to do it. Endoscopy right away. So those are the patients that you treat with DPIs, meaning antacids, for like two or three months and then see them back in clinic and see how they're doing. If they're still through maximum dose therapy, still not doing good, and they're still having these symptoms, then you go ahead and get an endoscop. But specifically, patients have alarming symptoms. You don't have to wait that time. Weight loss, early satiety, blood and stool vomiting, blood. those are patients that you want to. Patients who are high risk. Patients with a family history of gastric cancer. Patients with the family history have other types of cancers. Patients with a known history of H. Blori, for example, like all those patients are at a higher risk. And you don't have to wait so long, you just go ahead, given an up endoscopy on them.
>> Debra Schindler:If someone has more pronounced symptoms, does that mean that they are in a, more advanced cancer stage?
>> Dr. Walid Shalub:advanced symptoms, very subjective matter. and depending on the loc, again, dep on the location of the cancer too. So just like I told, because stomach cancer has space to grow, if it's more on the proximal side, meaning more in the upper stomach, you tend to feel it less than if it's more towards where the stomach empties into the intestine. Because if it's closer to where the stomach empties into the intestine, then that tumor or that mass is going to start to grow and start to block the food passing. And that's when you start getting the sense of early fullness, the sense of vomiting and those alarming signs. So it is very subjective again. But those patients, it depends on where the cancer is. Usually that's how quickly or how acutely they do present.
>> Dr. Ritu Mukherji:Kind of in line with what Dr. Shalub is saying. The symptoms related to stomach cancer sometimes can be specific, but many times are very nonecific. And there's so many different things that could cause these symptoms of early satiety, pain, acid, reflux, dyspepsia symptoms. And it can kind of be hard to tease out without taking a direct look what exactly is going on. Now like he mentioned where the location of the tumor is. You know, some people can just have a localized tumor higher in the stomach and be very symptomatic compared to someone with one farther away. Not quite walkocking off the food pipe and the esophagus. but when we talk about advanced cancer, meaning cancer that may have spread outside of the stomach to the, to other organs, you know, this can also be very non specific. But some patients can have symptoms such as pain in certain parts of their abdomen. Farther away, if things have traveled to the liver, they may have lymph nodes that were swelling in certain areas of the body that look larger. And and sometimes when stomach cancer can spread to the lining of our abdomen called the peritoneum, we can develop swelling and fluid that builds up in the belly. So very non specific symptoms. But with very advanced cancer it can be a little bit more than just the typical nausea, vomiting, dyspepsia, but maybe also pain in different part parts of the body.
>> Debra Schindler:I'm sorry, what's dyspeppsia? Yeeah.
>> Dr. Ritu Mukherji:That refers to symptoms related to a lot of acid buildup and acid reflux. So this can be in the way of burping, belching, pain or a burning sensation in the throat, in the chest, and even maybe a metallic or bad taste in the back of the mouth. So symptoms areion.
>> Debra Schindler:So the first step in getting a diagnosis. You mentioned the endoscopy. Let's go down the list. Then we got a physical exam, the endoscopy, what's the tumor markers test?
>> Dr. Ritu Mukherji:So tumor markers, can refer to a few different things, but you we can start with talking about blood tumor markers. So there are certain blood tests that we can look for, look for proteins that are expressed by some of these cancers aberntly or in higher levels that they can spill out into the blood. An example of this is a marker called CEA or another one called CA99. So these are blood tests that look for protein levels. But it's very important to know that these are not very specific. They do not diagnose cancer in and of itself. They can just be signs that maybe something is going on. They can also be elevated if there's inflammation or infection. So, again, not very specific for cancer. so tumor markers in the blood are something that we commonly test when someone is first diagnosed, but they are really not the most important part of the diagnostic algorithm. The way to diagnose is if you have symptoms, you take a look. If there's a mass, you biopsy, and you figure out what is it? A stomach adenocarcinoma. and we can talk a little bit more about the next steps in the way of staging, which are important. And, what we want to know next is how advanced is it? How far has it traveled, or is it just where it started? And the way we look at that is by doing CT scans, which look at the chest, abdomen, and the pelvis. If we find that the cancer seems to be localized, even if it's to some of the nearby lymph nodes, ah, we often will send patients back to somebody like Dr. Shalou to do something called an endoscopic ultrasound, which is very similar to the endoscopy that first happened to get the biopsy. But this time we're using an ultrasound and imaging probe to try to get a better understanding of how deep through the wall did the cancer travel and is it in the nearby lymph nodes. So this helps us better stage cancers. How locally advanced may they be?
>> Debra Schindler:And the patient is asleep for the endoscopic ultrasound, correct?
>> Dr. Walid Shalub:Yes, yes, yes. So endoscopic ultrasounds are just like a regular endoscopy, but just the actual endoscope itself has an little ultrasound machine right at the tip of it, very tiny one. And it has that ultrasound, capability and capacity. And just like Dr. Mu was saying. So once you do diagnose them, let's say somebody did get an upper endoscoping the community, and they found this, mass, and then they biopsied the mass, and the mass came back to adenocarcinoma. For focusing on. Specifically on adenocarcinomas, the CT scan is very important to stage, to see if it's gone anywhere, because if it's already gone to different parts, like the liver or, the lungs or. So you don't really need e. US because an US Is very focused on local staging and to make sure that this is resectable or to make it resectable, because you can give them chemotherapy and radiation therapy to shrink the tumor first and then get them to a resectable st so, CT scans are very important. The first step in making sure that these patients are either in the yes or in the no of getting treatment. Or even in thees or in the no. They all get treatment, but in the yes or in the no of them becoming surgical camid serv, not like, intent to cure. Pretty much just like you're asking. Yes. patients are completely asleep. The risks of them are just like any upper endoscopic procedure. You go in with the probe itself, the ultrasound probe, and you figure out where the cancer is. And then our GI tract is pretty. Explain this very quickly. Our GI tract is the actual stomach itself is comprised of five different layers, something called the deep mucosa. Then there's, the submucosa, there's the muscular superficial mucosa, deep mucosa, submucossa, muscularis propria, and then the actual, outside lining. And these five linings are very important because the level of invasion into these layers, dictates what the type of treatment is. So an EOS is very sensitive and specific. The ultrasound is to show us how deep this mass does go into the layers of the stomach. So, and then these are divided in something called a T stage. So there's something called a T stage, an end stage, and an M stage. I'll explain these to you as well. These are very technical, but at T stage goes by how big the cancer is and the level of invasion into these different la of the stomach wall that I was talking about. And then the ultrasound can also look at the nodes. You can specifically, you can specifically see if there's any nodes around the actual cancer cell. Because having nodes versus not having nodes is also a huge critical point in dictating the treatment of what the next step should be. And then with metastatic disease, us is usually not good, because metastatic disease is when, the cancter goes to separate parts of the body. And again, like I said in ewas is very focal, very, targeted test. It just takes a look at this mass itself, and if it's really deep and how deep it is into the stomach wall.
>> Debra Schindler:When you say he nodes, do you mean havingy nodes show up positive for cancer?
>> Dr. Walid Shalub:Okay, she see a lymph node on us means that it's pathological. Usually lymph nodes do not appear on ultrasound. Just by the definition of you actually being able to visualize the lymph noes, you'have to bow up.
>> Debra Schindler:Just seeing them tells you that there's cancer.
>> Dr. Walid Shalub:If you already have proven cancer right endoscopy that's, that's when you go for the ultrasound.
>> Debra Schindler:I see.
>> Dr. Walid Shalub:So you already know you have cancer. Any node, if you do see it on ultrasound, is considered a positive node. Because usually you never see nodes on.
>> Debra Schindler:Ultraso, which indicates that it has spreadit.
>> Dr. Walid Shalub:Correct into the nodes, doesn't mean that it has gone everywhere in the body.
>> Debra Schindler:But that will tell you that you need to treat this in a certain way.
>> Dr. Walid Shalub:Corre which this is where this is very important information that I give to read to. And rito tailors their treatment according to what I find on ultrasound. And ro you can tell them exactly what.
>> Dr. Ritu Mukherji:Yeah. So Dr. Shalub alluded to the different layers in the stomach wall. So if there's very superficial mucosal kind of the first layer involvement, and the cancer hasn't spread beyond that, hasn't spread deeper, and it hasn't spread to the lymph nodes, Sometimes, a GI doctor like Dr. Shalub can just do a local procedure like a resection, an endo mucosal resection to try to cure or somebody of this very early stage cancer. Now, if the tumor we find has traveled deeper through the wall, through the muscle wall, even before the muscle wall, just what we call the submucosal layer, even if you don't see nearby lymph nodes, the risk that the cancer is travel to the lymph nodes increases significantly. So while an enduccosal resection, a local surgery or procedure may not be enough to cure, that's when we send patients to a surgeon, and they'll do a bigger operation, something called a gastrectomy, where part or the whole of the stomach comes out. But not only the stomach, they will also take out the lymph nodes and the tissue around the stomach. Given that there's a higher chance, even if we don't see it, that the lymph nodes have become involved with cancer. Now, at the time of staging, if we find either the tumor has gone deep through the wall of the stomach, or if we see it, a lymph nodes had been involved up front, we call those cases locally advanced cases, localially advanced stomach cancer. And the risk of recurrence after a surgery is higher with this stage. And so in these cases, often I will see these patients or somebody in the medical oncology group, and we are offering patients some form of perioperative treatment. So this is typically in the form of chemotherapy given for two, three months before and then even given again two, three months after surgery to improve the odds of Cures since these patients are higher risk. So that's why it's so important upfron to fully staged patients, make sure it hasn't spread farther away. See if the lymph nodes are involved, how deep through the wall has it traveled? Because that will really dictate the optimal treatment for patients for cure.
>> Debra Schindler:When you go and you biopsy a patient, have you found them usually to be in a later stage? Because of what we talked about earlier with the symptoms being so random.
>> Dr. Walid Shalub:Yeah. So I'll tell you this. Most cancers that are diagnosed from patients feeling them are already T3's they've already invaded that stage three. Yep. Stage three. Correct. Usually very early cancers are incidental cancers because you don't feel them unless like somebody was very vigilant, had a lot of heartburn or had a lot of epigastric pain. And then their gastroenterologist has, very low tolerance to treatment first and then them coming back. Those are the early stage cancers. So ESCs, they're called early stage cancers. And those cancers are usually less than 2cm in diamet. They just like Dr. Muum was saying, they don't tend to involve the muscularis layer. Those are patients who can get some get a very deep resection called an ESD or a dmr, where you go inside and you tunnel and you dig them all out. Those are patients that mostly are found incidentally rather than them feeling it.
>> Debra Schindler:I did read that in some cases genetic or molecular tests may be done on the biopsy tissue. Which cases are selected for this and what information can be gleaned from these tests? Absolutely.
>> Dr. Ritu Mukherji:so molecular testing is incredibly important in that when we diagnose stomach cancer, and I will say, you know, most often we are testing it, very routinely, in patients who have advanced disease. So we're talking about patients who are unfortunately, cancer has spread spread to the liver, lungs, farther away, or they may not be candidates for surgery in that case. and the reason it's so important so this is doing molecular testing, DNA analys protein analysis on a tumor sample. The reason it's important is because we know that if certain patients have certain mutations or certain markers, they are eligible for therapeutics that target those markers specifically that have been shown to have survival benefits. And so, sometimes these therapies that are targeted could be used with chemotherapy. Sometimes they're used alone. And there are many different targets that we can talk about. So especially in advanced disease, when we're talking, even if it's palliative treatment, very important to test. Actually, the first treatment we give people with advanced disease depends very highly on molecular testing. So, often I'll ask Dr. Shalub to go back and get me some extra tissue because we need enough tissue to run these tests, and we need to get it on all these patients upfro front. Now, while a lot of these therapeutics are approved and have shown survival benefits in the metastatic or advanced disease setting, we are now starting to move some of these therapies and test them, in earlier stages of cancer. So we're talking about the curative setting. So for patients who are going for surgery right now, the standard of care for locally advanced disease who are resectable is, as I mentioned, some chemotherapy before and after surgery for the vast majority of patients. Question is, should we start using some of these targeted therapies in that setting, adding it to chemotherapy before and after? Now, there have been some studies that have looked into this. Really. there's no approved agent right now that we add to chemotherapy, but there are some promising results from studies using things like immunotherapy or targeted therapy, such as directed towards HER two. So in my practice, I like to know molecular profiling in all the patients that I see, Absolutely, the metastatic patients who are not going for surgery. But even now, for patients who may be surgical candidates with locally advanced disease, there are certain markers I want to know, because we do have data that actually g immunotherapy to a certain subset of patients. This is the minority of patients, but these patients can do much better than with chemotherapy. this subset, what we're talking about are patients who have this marker called microsatellite instability, also known as mismatch repair deficiency. And just very briefly, what this means is these patients have tumors that make a lot of mutations. They're very abnormal. and when we give immunotherapy, which are drugs that pretty much activate our body's immune system to try to recognize cancer and go after it, we think these tumors with a lot of mutations are better recognized intrinsically by our body's immune system. So immunotherapy works especially well here. so it's important to know, even in patients who are surgical candidates, if they have this marker, because we have some phase two data that supports giving immunotherapy rather than chemother in these cases.
>> Debra Schindler:And immunotherapy that falls under the targeted therapy category. Is that an infusion? Are they pills? Give us a little what a patient or what somebody Might expect if they were told it's a good option for them.
>> Dr. Ritu Mukherji:So I guess, let me go back a little bit. And, you know, what is chemotherapy? Chemotherapies are drugs. They can be pills, they can be IV Drugs that essentially damage DNA. And cancer cells are rapidly dividing DNA to grow. So chemo works by damaging that process and essentially killing cells so they can't divide cancer cells. Immunotherapy is very different. There's actually different types of immunotherapy. there are some immunotherapies that block, essentially block signals that allow cancer to hide from the immune system. There are other immunotherapies that are essentially infusions of immune cells, Whether it be your own immune cells or others. But specifically, when we talk about immunotherapy and stomach cancer here, the ones that we have approved in advanced disease, these are drugs called checkpoint inhibitors. The way I describe it to my patients is I say, you know, your cancer is smart. It has a way that it hides from the body's immune system. It puts up a little marker on the cell surface that says, don't kill me. don't eat me. I belong here. And immunotherapy, or drugs, checkpoint inhibitors, are antibody drugs that go and block that don't kill me signal. And essentially that unmasks cancer from our body's immune system, allowing our. The body's immune system to go after cancer. So that's an example of checkpoint inhibitors that. Those are drugs that we use in stomach cancer today. And the drugs that we have today are infusion therapy. the common one, really. The ones that are approved are nvolumab and pembrolizumab. And these are infusion therapies given in the infusion center through the IV. We do not yet have a pill form of this.
>> Debra Schindler:Okay, so you had mentioned that some people weren't candidates for surgery, and that's probably bad news, I would think. Who gets surgery and who doesn't?
>> Dr. Ritu Mukherji:For patients with localized disease, if it has. Even if it's locally advanced, even if it's traveled to the nearby lymph nodes, and if they're strong enough and a surgeon says, hey, I think I can take this patient to surgery, we are trying to get those patients to surgery to cure them. So localized, locally advanced disease, the goal is to try to cure. Now, when the cancer has spread outside of that local area, if it's gone to the liver, the lung, or even a lymph node farther away, unfortunately, that's when we call. We think that the cancer has become systemic. It's learned how to spread through the blood vessels. It's not contained anymore. And, surgery is very unlikely to cure these patients. So stage four disease, metastatic disease, for the most part, unfortunately, is incurable.
>> Dr. Walid Shalub:A lot of patients who would be surprised just once, they describe to them what the outcome of a surgery is, sometimes opt out of it. Although you can tell them this is curable, you know, but they just don't want to deal with with no stomach, living without a stomach. Any stage that we stage on E West, that's more than a T1A, which is early stage one. Cancer needs something called a diagnostic laparoscopy, where we do go into the stomach, very minimally, invasively inflate the stomach, take a look around, make sure there's no distant metastases. Because gastric cancer cells love to go to the oentum. They like to live inside that cover of the intestine. So we take a look, make sure there's nothing there. And then those are the patients that we feel comfortable for them to, get a partial or totalal gastrectomy as well as ne adjuvant chemotherapy with Dr. Oji.
>> Dr. Ritu Mukherji:I'll just add that maybe the last, staging thing that we might use, in addition to the CT scan, the endoscopy, the endoscopic ultrasound, and the diagnostic laparoscopy, sometimes we will also get a PET skin, which is a different type of imaging. and PET scans light up bright where there's a lot of activity, where there's a lot of cell growth, cell turnover. So cancer tends to light up bright. And this is another way to just take one more look and see, is there cancer anywhere else besides locally? now, there are certainly limitations to all of these diagnostics. And PET scans may not always pick up things nicely at the level of the lining of the abdomen, the peritoneum. And that's when things like the diagnostic laparoscopy are very helpful to take a more granular, closer look and make sure we're not missing any small amount of cancer. And so we're choosing the right patients to go for a big operation like a surgery.
>> Dr. Walid Shalub:And, I'm glad you actually brought up PET scans for dist Metostatic disease. If somebody gets a ct, the initial CT that we were saying, once you get endalloscopy, you take the biopsies, they'cancer. Then you get a CT. If the CT'isn't really sure about distant metestices, these are patients also benefit From a PET scan as well.
>> Dr. Ritu Mukherji:And ultimately if we are left at a point where we're not really sure, we always try to get a biopsy because it's just so important to make sure we fully stage people properly to not take off off, you know, the option for surgery in patients who may be eligible.
>> Dr. Walid Shalub:And just one thing regarding the lymph nodes, I just want to make sure that it's there. So lymph nodes that are adjacent to the mass and you can actually see them. Those are the ones that don't need biopsy. But let's say there's another lymph node that's a retroper to nail or something that's abnormal that did show on a PET scan or on a CT scan. Those who knows that you have to go after and you have to biopsy to make sure that they don't have cancer involved.
>> Debra Schindler:What do you mean my retrop perineal?
>> Dr. Walid Shalub:Just anatomically in the stomach there are some nodes that are not just adjacent to the. Because lymph nodes in our body are distributed in specific areas, or concentrated more in specific areas. The ones that are concentrated next to the stomach is the retroper to name that is an anatomic place. If one of them is larger, you would want to go after even if it's not adjacent to the actual lesion in the stomach itself.
>> Dr. Ritu Mukherji:Yeah, Debra, I think here it's kind of especially if the lymph node is felt to be outside of the field of what a surgeon is going to remove, which would technically make someone maybe stage four or advanced metastatic rather than locally advanced. Those are the lymph nodes that we would typically want to go biopsy and make sure.
>> Debra Schindler:And then you would refer them to perhaps for. You mentioned the gastroctomy.
>> Dr. Walid Shalub:The gastrectomy. Correct.
>> Debra Schindler:For stomach removal. And I know we don't have a surgeon here to talk about that. But once that stomach is removed and the stomach cancer in theory is gone, is that to say that the patient is cured? And what has been your experience with long term results for patients?
>> Dr. Walid Shalub:That is an excellent question. The most important thing is to if. If you do go for curative intent and it's taken out and they get their chemo and I do my job correctly and r. It does their job correctly and everybody. Patients can't just go skip it along for the rest of their life. They have to be on a specific regimen of surveillance. And that is what. This is how you keep these patients healthy and happy. These cancers tend to recur. Because if somebody's genetically predisposed to cancer, they got it in the first portion of that stomach. The fact that they actually have a gastric cancer puts them at a higher risk of them developing it later again in life if they rec cured the first time. You know, so it doesn't mean that it's just that coda, that you're going to have that one lesion in your stomach and you're dumb. I'TALKING about patients who have just part of their stomach, because not all patients have all the stomach taken out the margins. Most of the times when they do take them out, the surgical margins are negative. And that's how you know somebody is cured or on the course of getting cured, you take it out, there's nothing in the surgical margin. They get chemo, they get a CT scan, a six months later, everything's negative. Their PET scan, if they go five years and nothing's there, I guess a cur is five years, right? Rita?
>> Dr. Ritu Mukherji:Or typically we'follow people up to five years. We say the majority of relapses or recurrences. If it were going to happen, it typically is in the first two to three years. It can even happen up to five years. But then it becomes exceedingly rarer if cancer is still there to recur after five years. So five years is typically the mark that we use.
>> Dr. Walid Shalub:I think most five years, you need to make sure that you survey them. Upper endoscopy, CT scan, possibly PET scans as well.
>> Dr. Ritu Mukherji:Just kind of going back to your point about, you know, surgery. Is it done? It's not so simple, you know, because as Dr. Shalubu was saying, there's different risks of recurrence or the fact that there might be microscopic rece resual disease out there. So the decision for know if someone goes for surgery up front, you know, we thought they had an early stage cancer, they go for surgery. It's still very important to look at the pathology and maybe have them see a medical oncologist afterwards as well. Because some patients, when we do surgery, we find that they had more than actually what we first thought with the staging scans. And if that's the case and they didn't receive any chemotherapy before, they may be candidates for chemother after. But for some very early stage cancers, they may just need surgery and that's it. And as Dr. Shalu mentioned, we recommend routine surveillance scans in the way of CT scans every few months, endoscopy. and I actually started incorporating a, technology called circulating tumor DNA this is something that our field is pretty excited about. It's not quite made its way into our guidelines for stomach cancer, but I think it, we think it's a very strong prognost. And when we talk about biomarkers, this is essentially a blood test, that you just draw blood from a patient and you look for a signature, this DNA signature that was in their original cancer. And essentially a CTDNA test says yes, I detect this person's cancer DNA in the blood or no, I don't. And there are many different assays out there. But what we learned is that if you have a positive CTDNA test, you detect patients cancer in the blood. That's typically bad news. There's 9,500% chance that there's still some cancer out there, even if you can't see it on a scan. So what do you do with this information, especially if the scans don't show anything? That's really the question that our community has. We know that we've identified a high risk situation. They've completed all their standard of care therapy. There's still something small floating out there. We just can't see it. What do we do? How do we treat it? Do we treat it or do we just wait until we see cancer come back on a scan, which is our standard of care today. So you know, at Georgetown we actually have a clinical trial treating in that setting where we find these high risk patients using this novel technology. And many of us are using CTDNA in clinic to just give extra information about know. Is there still something out there even if our scans can't show it? and there's different strategies that we might use to treat in that setting, Although we really don't have guidelines to tell us what to do yet.
>> Debra Schindler:There is there a connection between stomach cancer and other cancers like esophageal or colorectal?
>> Dr. Ritu Mukherji:I mean stomach cancer. We used to kind of treat esophageal GE junction stomach cancer similarly. We thought they were all on the spectrum of the upper GI tract. But we do appreciate now that they are very distinct entities. In fact, they're molecularly different, they behave differently. but there are some stomach cancers that live a little bit higher up in the stomach, closer to the esophagus, the GE junction, they're treated fairly similarly. Now when you talk about is there association with esophageal cancer and other cancer, I think typically we're thinking about maybe hereditary syndromes there where there may be something passed on in a family that predisposes an individual or family members to develop multiple cancers. and there are certain syndromes. For instance, lynch syndrome. this is a syndrome that people can be predisposed to colorectal cancer, endometrial cancer, pancreas cancer, even gastric cancers as well. So there are certain things we look for in family histories and if it ringss off any bels, we send patients to genetic counselors to get genetic testing done. There's also other syndromes like leafroni syndrome with different mutations that are passed on in the family that can predispose people to not just stomach cancer, but also cancer. So especially if we see someone with multiple cancers or family members with that, we will think about something like a hereditary syndrome. I think otherwise, if somebody had kind of the same risk factors that apply to stomach cancer as they went to something like colorectal cancer_er or even a, nasal cancer, there's some overlap in the risk factors for people that develop nasal cancers, esophageal cancer, stomach cancers, for instance, smoking. those risk factors can predispose people to multiple cancers at once.
>> Dr. Walid Shalub:The only one, I would also add something called putzger is also a syndrome that if you do have pger, you are at an increased risk of developing a gastric cancer, pancreatic cancer, colorectal I think. And those are three main ones. But the most important one that we do see a lot of is lynch syndrome. Lynch syndrome has a direct correlation with gastric cancer and colorectal cancer. And these are, connected together. So if somebody has ly syndrome, they're on a schedule of getting regular upper endoscopies and colonoscopies at the same time to make sure that they did not develop cancers in either their stomach or their colon.
>> Debra Schindler:What advice do you have for people who suspect that they might have a stomach cancer?
>> Dr. Walid Shalub:Patients with alarming symptoms. So weight loss is a big one. Increased satiety is a big one. Family history is a big one. At a young age. a history of a non, healing ulcer that they've been scoped before. They said, oh, this is just peptic ulcer disease. And it's just non healing and it's just going over. It's been three months and you're putting on maximal therapy. And those are patients that you want to make sure. You get a ct scan, you get an e. Us just to make sure that these ulcers are not deep. And they're a type, also type of adiror syndrome that is very aggressive. So, Those are patients that I want to scope. So non remitting symptoms m despite maximal therapy is a big one for me to go ahead and do them and all the other riskcribes that we talked.
>> Dr. Ritu Mukherji:About just to add to that know, fortunately the incidence and even the death rate from gastric cancer has been decreasing over the past few decades. But there has unfortunately been an alarming trend for higher incidence of younger, onset ##I cancers. We talk a lot about this in colon cancer, but it's also a trend that we're seeing in stomach cancer. So sadly we are seeing younger and younger people in the medical oncology clinic with these cancers and they certainly would not think to go screen for this, especially as we don't have screening guidelines and often have very nebulous symptoms. So know, just encouraging patients if they have symptoms that are non remitting. Like Dr. Shalub said, risk factors in the family. Meet with your primary care doctor, have a discussion about your symptoms, the longevity of it, family history and you know, low threshold to see a gastroenterologist and discuss whether you're a candidate for something like an endoscopy to take a closer look. But there are unfortunately disproportionately affected populations in the United States who are diagnosed with stomach cancers. We see higher rates in Hispanic population, black population, even Native American and Alaska. So there are some groups that we need to think about a little bit more when they come to us with symptoms, whether it be the primary care, the GI doctor or even medical oncology to just see if they might be higher risk and warrant a closer look.
>> Debra Schindler:It's a complicated cancer really, with a lot of variables and no clearar cut path to treatment. It seems between you've probably had hundreds and hundreds of patients. So reflecting back on your cases, is there one that stands out that would give other people significant hope?
>> Dr. Walid Shalub:Actually yes, I do have, multiple patients that do stand out. Patients who had early cancers that were diagnosed, resected and they're five years out and they're completely asymptomatic, very happy, and went on to lead normal lives, you know, after their diagnosis. One thing I would really keep any patient, with is to make sure that never to take symptoms lightly. You know, a lot of patients, specifically older men, tend to push a lot of their symptoms out of the way. And those are the patients who unfortunately come to you and they're already at a stage where you can't do anything to them that would extend their life, making sure that they don't Take symptoms lightly, making sure that they don't smoke, making sure that they watch their diet, making sure, you know, those are all things that are preventable, that you can prevent. You obviously can't prevent your genetics, but the things that you can prevent, I think they need to be very vigilly aware and to go ahead and do.
>> Dr. Ritu Mukherji:Yeah. In my clinic, you know, I see patients not just early stage, but also late stage. And so more than just one example, but one that pops to mind is, you know, I have a very elderly gentleman who came in with stomach cancer. It was localized. Wish we could go do surgery and cure him. But he was not a surgical candidate. He was too old, too frail. He got molecular testing done, and he was in that 5, 10% of patients that had that marker that suggested he might do well with immunotherapy. So, so he's seven months into immunotherapy, and the tumor has really melted away. He might be cured, it might be there microscopically, we don't know, but good quality of life. And, you know, I, I think the purpose of that is to really highlight, you know, getting that consultation, getting the molecular testing done, because you don't know what other options you have besides surgery, radiation, chemotherapy that you may be eligible for. And truly characterizing the tumor opens the door for some patients, not all for some of these other therapies. And on the other side, in advanced disease, you know, we certainly have a lot of room for improvement when cancer becomes metastatic. The median survival, we want to see numbers better than a year, two years, which is where we really are with some of our different subtypes. And some patients do better than others. And the molecular testing is so important. I have an older gentleman who, almost 90, and he has good quality of life. He doesn't know, he doesn't feel that he has metastatic hand, but he's doing well with stability on a targeted therapy. You know, everybody's case is different, and I think just keeping, you know, options open, getting the consultation, molecular profiling done, seeing what, you know, there's a chance that you may benefit from certain targeted therapies. And you don't know until you take a look at the molecular data. And finally, clinical trials. Right. We need to get patients on clinical trials. Every drug we have today came from a clinical trial or weest and showed a survival benefit. And, you know, I have some patients who have gone on trials and they've done well. they don't work for everyone, of course, but, you know, those are really the cases that stick out to me, I think very important to be considering that in, you know, really any stage of the disease.
>> Debra Schindler:Well, you guys, know your stuff, and I've been really enthralled to speak with you.
>> Dr. Ritu Mukherji:I much this is really good. You know, I think patients, it is a lot for them to take in at these meetings. We have multiple ones with them, but podcasts like this and other resources online, I think, really will help for people who are looking for more information.
>> Debra Schindler:Thank you.
>> Dr. Ritu Mukherji:Thank you.
>> Dr. Walid Shalub:You are pretty inquisitive, I have to.
>> Debra Schindler:Say, but, it's very interesting. Likewise. Thank you so much, and thank you for giving me so much time. We've been talking with gastroenterologist Dr. Walib Chalub and medical oncologist Dr. Ritu Mukoji. For more information, go to medstarhealth.org cancer.
